RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00952
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051214

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Military Police, medically separated for “chronic radiating neck pain” and “chronic left shoulder pain,” rated at 0% each, respectively, with a combined disability rating of 0%.  

CI CONTENTION:  The CI made no specific contention.  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting or non-compensable.  Any conditions outside the panel’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition(s) at the time of separation.  The panel has neither the role nor the authority to compensate for progression or complications of service-connected conditions after separation.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The panel gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20051013	VARD - 20060831	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Radiating Neck Pain	5299-5237	0%	Degenerative Changes of Cervical Spine	5242	10%	20060411	
Chronic Left Shoulder Pain	5099-5003	0%	Degenerative Changes of Left Acromioclavicular Joint Shoulder Impingement	5003
5201	Deferred  20%	20060411
20060701	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Radiating Neck Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s neck condition began in 1999 spontaneously and included numbness in his left hand.  The CI denied any specific injury or trauma.  Radiographic studies showed cervical degenerative disc disease (DDD) and cervical stenosis at C5-7 with disc or spurs flattening the cord at C5-C6.  

At the time of the 18 July 2005 orthopedic clinic appointment, 5 months prior to separation, the CI reported pain to his neck, pain to the left shoulder; and pain down to his coccyx posteriorly, with numbness in his left middle finger, ring finger and thumb.  The CI was being treated with Meloxicam (anti-inflammatory/analgesic) and a muscle relaxant with no relief of his symptoms.  The CI detailed the pain became severe and sharp with exercise.  Physical examination showed the neck appeared normal, with normal cervical contour and no muscle spasm.  The range of motion (ROM) was reported in a nonstandard manner as:  “The position of the cervical spine at rest is 40, 42 lordosis.  Flexion is to 9, 10 degrees lordosis, to within 2 1/2 inches of the sternum.  There is extension to 50, 53 degrees.  Lateral bending is 17, 17 degrees right and 16, 16 left.  Rotation is 43, 43 degrees right and 19, 51 left.”  Neurovascular examination showed motor, reflex, pulses and sensory intact except for decreased light touch of the volar tips of the left thumb, ring and middle fingers noted.  There was no surgical indication.  Diagnosis was cervical degenerative joint disease (DJD) with cervical stenosis C5-7.  

Physical Therapy consult evaluation, dated 1 August 2005, 4 months prior to separation, for cervical stenosis and left shoulder impingement, noted complaints of neck pain with activities and numbness/tingling of the left thumb and 3rd and 4th fingers.  Physical examination showed “C-spine clears in all plains with sustained overpressure with pain.”  Strength, reflexes and sensation in the upper extremities were intact.  Left upper extremity symptoms were reproduced with neck extension and left rotation.  Electrodiagnostic studies, 16 August 2005, were negative for radiculopathy.  

During the September 2005 MEB examination (recorded on DD Forms 2807 and 2808), 3 months prior to separation, the CI reported chronic neck pain.  Physical examination showed “painful ROM with limitation” (degrees not specified).  The 7 September 2005 MEB NARSUM, 3 months prior to separation, was accomplished by the orthopedic surgeon who examined the CI on 18 July 2005.  The CI had complaints of neck pain and episodic left hand numbness and the history and examination were the same as the orthopedic examination from 18 July 2005.  There was no surgical indication.  Diagnosis was cervical degenerative joint disease (DJD) with cervical stenosis C5-7.  

At the 11 April 2006 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported chronic pain in his neck (posterior and at the base), and between his shoulders.  Pain was rated at 8/10, occurring on a daily basis, and prevented him from bending, lifting over 15lbs, or standing for greater than 45 minutes.  Flares reported at 10/10 on a pain scale, occurred almost daily.  The CI detailed that he was unable to gain employment due to the chronic nature of the pain.  Physical examination showed upper extremity reflexes, muscle strength, and sensation were intact.  Cervical ROM was flexion to 35 degrees (normal 45) and combined 270 degrees (normal 340), and repetitive motion increased pain and stiffness.  Radiographic studies of the cervical spine showed a normal lordotic curve with disc spaces preserved.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 0%, coded analogously to 5237 (cervical strain), citing motion limited by pain, no tenderness, spasms, or radiculopathy; “rated for pain-limited motion.”  The VA rated the neck condition 10% coded 5242 (degenerative arthritis of the spine), based on the C&P examination 4 months after separation, citing cervical ROM criteria.  

The panel noted that the NARSUM and orthopedic surgery treatment and evaluation notes all had the exact same examination findings, and that the forward flexion ratable measurement was non-standard noting cervical rest at 40 degrees lordosis and cervical flexion to 10 degrees lordosis, and/or “within 2 1/2 inches of the sternum.”  The panel majority did not adjudge that interpretation of that examination to forward flexion limited to 10 degrees, or to 30 degrees or less, was consistent with other objective findings of the examination, the PT examination performed 1 month earlier that showed “clear in all planes with sustained overpressure and pain” which would not corroborate a ROM limitation of 30 degrees, or to the preponderance of the cervical evidence in the record.  The panel majority adjudged that the VA examination proximate to separation was more detailed, and aligned with the preponderance of the evidence in the record and therefore the panel majority placed greater probative value on the VA examination.  

The panel majority agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 40 degrees) and combined ROM (greater than 170 degrees but not greater than 335 degrees) reported on the separation VA examination after examination.  There was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  There was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 10% for the neck condition, coded 5299-5242.  

Chronic Left Shoulder Pain.  According to the STR and MEB NARSUM, the CI’s left shoulder condition began in 1999 spontaneously with neck pain and numbness in his left hand.  The CI was right handed and denied any specific injury or trauma.  At the 18 July 2005 orthopedic clinic appointment, the CI reported pain in his left shoulder.  On physical examination the shoulder appeared normal, no atrophy, effusion, or tenderness to palpation was noted.  Stability was noted to be good.  ROM was flexion to 119 degrees (normal 180) and abduction of 133 degrees (normal 180).  The diagnosis was left shoulder pain with bursitis and mild acromioclavicular arthritis with degenerative joint disease.  Radiographic studies, 18 July 2005 and 1 August 2005, showed mild osteoarthritis and degenerative changes of the acromioclavicular (AC) joint.  There was no surgical indication. 

The 1 August 2005 Physical Therapy (PT) consult evaluation, 4 months prior to separation, was for left shoulder impingement and noted complaints of left shoulder pain aggravated by lifting overhead and activities.  Physical examination showed normal shoulder active ROM with painful arc.  There were positive impingement signs and painful motion (positive Neer, Hawkins Kennedy, and cross arm) of the left shoulder.  The diagnosis was left shoulder impingement.  

The MEB NARSUM examination was accomplished by the orthopedic surgeon who examined the CI on 18 July 2005.  The CI had complaints of pain in the left shoulder.  The history and examination were the same as the orthopedic examination from 18 July 2005.  The CI had complaints pain in the left shoulder (and episodic left hand numbness – see above) and the history and examination were the same as the orthopedic examination from 18 July 2005.  At the MEB examination the CI reported chronic left shoulder pain.  Physical examination showed “limited ROM in abduction and adduction with strength decreased” (no degrees or motor strength measures provided).  

At the 11 April 2006 VA Compensation and Pension (C&P) evaluation, performed 4 months after separation, the CI reported the left shoulder had progressively gotten worse with severe pain occurring weekly and lasting hours causing him to stop what he was doing.  Physical examination showed no muscle weakness, no atrophy, no spasms, and no joint laxity.  Bilateral shoulder tenderness was present and reflexes were normal.  Shoulder ROM was abduction to 90 degrees (normal 180) with internal rotation and external rotation 10 degrees (normal 90), and no flexion measurements were given.  The VA medical opinion dated 1 July 2006 confirmed the shoulder diagnostic imaging (MRI) did not indicate degenerative changes in the acromioclavicular joint or in the glenohumeral joint.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 0%, coded 5099-5003 (arthritis, degenerative), citing “rated for pain – slight occasional.” The VA rated the left shoulder condition 20%, coded 5201 (arm, limitation of motion), citing painful limited motion, based on the examination 4 months after separation and medical opinion 7 months after separation.  

The panel adjudged that the PT examination had the highest probative value for rating at separation.  The VASRD §4.71a threshold for rating for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and the examinations before separation in evidence demonstrated motion above this level.  Although there was insufficient limitation of motion to support a rating under the 5201 code, panel members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion).  There was no malunion or recurrent dislocation of the humerus to justify a rating under the 5202 code (humerus, other impairment of); and no nonunion with loose movement of the clavicle to warrant the next higher 20% rating under the 5203 code (clavicle or scapula, impairment of).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left shoulder condition, coded 5099-5003.  

BOARD FINDINGS:  In the matter of the chronic radiating neck pain condition, the panel majority recommends a disability rating of 10%, coded 5299-5242 IAW VASRD §4.71a.  The single voter for dissent submitted the appended minority opinion.  In the matter of the chronic left shoulder pain condition, the panel unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  There were no other conditions within the panel’s scope of review for consideration.    

The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Radiating Neck Pain	5299-5242	10%	
Chronic Left Shoulder Pain	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150607, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MINORITY OPINION

There was clear and compelling evidence in the STR that the CI’s cervical spine ROM was limited to 30 degrees or less and warranted a 20% rating at separation for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees.  

The key ratable issue is the active forward flexion of the cervical spine and which examination had the highest probative value for rating.  The minority voter strongly disagrees with the majority’s assessment that the orthopedic NARSUM examination was not interpretable within VASRD criteria, and that the post-separation VA examination had any higher probative value for rating at separation.  There were only three examination in evidence proximate to separation which noted cervical ROM (other than as painful and limited), and only two provide active ROM measurements.  All other notes indicated pain-limited cervical motion without specifying measurements.  

Although the orthopedic NARSUM cervical ROM measurements were reported in a non-standard manner and open to interpretation, the medical interpretation of the source examination was between a forward cervical flexion of 10 degrees or 30 degrees; with both measured degrees of lordosis at rest and lordosis with flexion equating to 30 degrees, and the “within 2 1/2 inches of the sternum” statement also equating to approximately 30 degrees or less, but greater than 15 degrees, of forward flexion.  The PT examination did not have an active ROM as the statement “C-spine clears in all plains with sustained overpressure with pain” indicates a non-ratable passive ROM with the examiner pushing the cervical spine flexion beyond where the CI would actively move, and indicated only no mechanical blockage.  The post-separation VA examination documented 35 degrees of cervical flexion which can be accounted for by post-separation improvement and aligned fairly closely (within 5 degrees of flexion) with the NARSUM examination measurements.  

There was no preponderance of evidence in the record indicating that the CI had any active ROM greater than 30 degrees in any notes in the year prior to separation.  Diagnostic imaging showed significant cervical pathology that would corroborate with a 20% cervical spine rating and the decreased active ROM recorded by the orthopedic examiner (disc or spurs pushing the thecal sac and cord posteriorly and flattening the cord at C5-C6 level, as well as mild loss of height of C5 with straightening of cervical lordosis consistent with muscle spasm).  

The minority recommends a disability rating of 20% for the neck condition, coded 5299-5242, and agrees with the majority’s 10% rating for the shoulder condition.  

The Secretary is respectfully urged to consider the minority recommendation that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Neck Pain	5299-5242	20%	
Chronic Left Shoulder Pain	5099-5003	10%	
COMBINED	30%	

AR20170010005, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure